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NUR455 Final Exam With Complete Solution
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NUR455 Final Exam WithComplete Solution
What are the layers of the skin (most superficial to deep)? - ANSWER
Epidermis
Dermis
Subcutaneous Tissue
Superficial Partial-Thickness Burns (1st Degree) - ANSWER -these burns are
typically resolved within three weeks. It involves the epidermis, and the
dermis, and typically, it appears to be red, and sometimes blisters can appear
as well. These patients will complain about pain a lot with these burns.
-These burns will blister within 24hrs
Deep Partial-Thickness Burn (2nd Degree) - ANSWER -Go deeper into the
dermis, and the hair follicles along with the glandular tissue are now involved
too. These burns are very painful.
-Their skin appears waxy and is discolored
Full-Thickness Burns (3rd Degree) - ANSWER -the dermis along with
subcutaneous tissue is impacted along with eschar being present, but
otherwise the skin is intact
-hair, sweat glands, and nerve endings are gone
Deep Full-Thickness Burn (4th Degree) - ANSWER -Vascular space is affected
and is life-threatening. Can go down to the bone layer as well. These patients
are highly susceptible to sepsis as well.
,-Damage to all layers of the skin and goes down to the muscle and bone
-These patients are on 6-8weeks of antibiotics to decrease the likelihood of
infection.
-These patients do not experience pain, due to nerve endings being damaged
-burned area has to be removed
Emergent Phase of Burn Injury - ANSWER This is the paramedic. First, they
will make sure that there's no injury to themselves. They are going to try to
eliminate what is causing the injury
-Stop the injury: extinguish fires, cool the burn, irrigate chemical burns
-ABC's: establish airway, breathing (can they breathe?), and circulation (is
their heart pumping?)
-Give O2 and fluids via 2 large bore IVs
-Remove restrictive objects/clothing and cover wound
-Hypovolemic shock is a common cause of death in the emergent phase of
clients with serious injuries. Administration of fluids can treat this problem.
For burns classified as severe (>20%TBSA), fluid resuscitation should be
initiated to maintain UO> 0.5mL/kg/hr
-Onset of the burn injury to restoration of capillary permeability
-Risk for: SHOCK (hypovolemic)
-Things that you will do in the first 42-48hrs of the person being admitted
Fluid Changes: they will have decreased UO initially and they can have release
of K into the extracellular space causing hyperkalemia and this is b/c it can't
stay in the cells (remember, K is highest inside the cell) and so if the cells are
,damaged, the K will be released into the ECF causing hyperkalemia. Sodium
will be trapped in the edematous fluid, so you will have low sodium along
with metabolic acidosis d/t all of the fluid shifts
Acute Phase of Burn Injury - ANSWER -48-72hrs after initial burn injury
-Capillary permeability stabilized to would closure
-Preventing infection, alleviating pain, wound care, proper nutrition (need
higher caloric intake d/t hypermetabolism that is associated with burns),
monitor CBC, look for s/s of infection
Fluid Changes: fluid reenters the vascular space from the interstitial space, so
as the edema starts to go down, the fluid is shifting back into the vascular
space. You will now have FVO, because the fluid is shifting back into the
vascular space and this will increase UP. Sodium is lost with diuresis and d/t
dilution as fluid enters the vascular space, so hyponatremia is still found.
Potassium shifts from ECF back into the cells which can cause potential
hyperkalemia. Metabolic acidosis still remains, because we don't have
hemodynamic homeostastis
-If the fluid goes from the interstitial space back into the intravascular space
too quickly, this can cause HF and the pt can also have pulm. edema
· Pulmonary edema can result from fluid resuscitation given for burn
treatment. This can occur even in a young healthy person. Placing the client
in an upright position can relieve lung congestion immediately before other
measures can be carried out. To manage this, you need to get them on
diuretics to pull the fluid off
Rehabilitative Phase of Burn Injury - ANSWER -Burn healed to patient able to
function again
, -PT/OT, cosmetic correction, psychosocial support
IV fluids for burn injury - ANSWER · Burn injuries greater than 10% TBSA
and including the dermis result in circulatory compromise secondary to fluid
loss via damaged tissue, widespread vasodilation as well as increase capillary
permeability and fluid shifts (third spacing)
· Strict I&Os; Q4hrs
· Fluid resuscitation is calculated using the Parkland Formula
Parkland Formula: Lactated Ringer's Solution: 4mL x kg body weight x % of
TBSA burned. Day 1: half to be given in first 8hrs; half to be given over the
next 16hrs. Day 2: varies. Colloid is added.
· Fluid resuscitation rates will need to be adjusted to accommodate the
patients urine output
· Ensure that they have 2 peripheral IVs
· Output: at least 1mL/kg/hr
Adult TBSA (Rule of Nines) - ANSWER · Head and Neck: 9% (4.5% anterior
and 4.5% posterior)
· Right Arm: 9% (4.5% anterior and 4.5% posterior)
· Left Arm: 9% (4.5% anterior and 4.5% posterior)
· Trunk: 36% (18% anterior (chest=9%; abdomen=9%) and 18% posterior
(upper back=9%; lower back=9%))
· Perinium: 1%
· Right leg: 18% (9% anterior and 9% posterior)
· Left leg: 18% (9% anterior and 9% posterior)
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